A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend?
Ambulate the client every 1 hr.
Apply cold compresses to painful joints.
Withhold opioids until the crisis is resolved.
Administer oxygen via nasal cannula.
The Correct Answer is D
Choice A reason: This is an incorrect intervention, because ambulating the client every 1 hr can increase the oxygen demand and worsen the sickling of the red blood cells.
Choice B reason: This is an incorrect intervention, because applying cold compresses to painful joints can cause vasoconstriction and reduce the blood flow to the affected areas.
Choice C reason: This is an incorrect intervention, because withholding opioids until the crisis is resolved can cause unnecessary suffering and increase the stress response, which can trigger more sickling.
Choice D reason: This is the correct intervention, because administering oxygen via nasal cannula can improve the oxygen saturation and prevent further sickling of the red blood cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should not share razors with anyone, even if they are disposable. Razors can cause cuts and bleeding, which can transmit the HIV virus and other infections. The client should use their own personal hygiene items and dispose of them safely.
Choice B reason: This is the correct statement, because the client should clean bathroom surfaces with a bleach and water solution. Bleach is a disinfectant that can kill germs and prevent the spread of infections. The client should also wash their hands frequently and avoid contact with bodily fluids.
Choice C reason: This is an incorrect statement, because the client should not increase their intake of raw fruits and vegetables. Raw fruits and vegetables can contain bacteria, parasites, or pesticides, which can cause infections and complications in the client who has a weakened immune system. The client should wash and cook their fruits and vegetables thoroughly before eating them.
Choice D reason: This is an incorrect statement, because the client should not continue their hobby of gardening, even if they wear a mask. Gardening can expose the client to soil, dust, fungi, or insects, which can cause infections and allergies in the client who has a compromised immune system. The client should avoid activities that can increase their risk of infection.
Correct Answer is B
Explanation
Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.
Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.
Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.
Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.
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